F0757

J

Failure to Monitor Warfarin Therapy and Respond to Bruising and Drug Interactions

Eagle Grove, Iowa Survey Completed on 03-17-2026

Penalty

Fine: $100,055

Summary

Facility staff failed to ensure appropriate monitoring and management of anticoagulant therapy for a resident on warfarin whose regimen was affected by additional medications. The resident had a history of stroke, severe cognitive impairment, limited range of motion, and was care planned for anticoagulant therapy with goals to avoid discomfort or adverse reactions. The care plan directed staff to check INR per physician orders and to monitor, document, and report adverse reactions such as bruising and changes in mental status, but it did not include instructions on how to monitor INR or address interactions between warfarin and antibiotics. The January MAR showed warfarin administration and new orders for Rocephin and metronidazole, both of which can affect INR, yet there was no corresponding INR order on the MAR or TAR.

On the morning after the physician ordered antibiotics, nursing staff discovered a large 7 cm by 5 cm bruise on the resident’s mons pubis/penis area while the resident was on warfarin and antibiotics. Staff documented the bruise in a nursing note and faxed a note to the physician, but there was no documented follow-up assessment, no skin sheet, no photograph, and no initiation of increased monitoring specific to the bruise or potential anticoagulant side effects. The TAR, which required staff to document monitoring for signs of anticoagulant adverse effects, showed an entry of “N” (no symptoms) on the day the bruise was found and no documentation at all the following day, despite the presence of the bruise. Staff interviews revealed that some nurses and CNAs saw or were told about the bruise, but they did not notify the physician or the resident’s wife in a timely manner, did not complete an investigation for an injury of unknown source, and did not obtain an INR when the bruise was first identified.

The resident’s INR was instead checked by his wife two days after staff discovered the bruise, revealing a markedly elevated INR of 7.3, which she reported to staff. Nursing staff then contacted the anticoagulation clinic, received recommendations to hold warfarin and administer vitamin K or spinach, and were informed that Rocephin, metronidazole, and the recent illness could severely affect INR levels. Before staff could implement these orders, the resident’s condition deteriorated, with documented lethargy, inability to follow commands, drooling, and abnormal lung sounds, leading to transfer to the hospital where an INR greater than 13 and a large rectus sheath hematoma with hemoperitoneum were identified. Throughout this period, facility staff reported they relied on the pharmacist to notify them of drug interactions and did not have a standard expectation or standing orders for more frequent INR checks when residents on warfarin started antibiotics. The DON acknowledged that staff failed to investigate the bruise as a potential injury of unknown source and that there was no standing process for INR monitoring frequency when high-risk medications such as antibiotics were added to warfarin therapy.

Surveyors determined that these failures constituted a deficiency in ensuring the resident’s drug regimen was free from unnecessary drugs, specifically by not adequately monitoring the INR and not responding appropriately to signs of possible anticoagulant-related bleeding while the resident was receiving interacting medications. The Department of Inspections, Appeals, and Licensing determined that the situation rose to the level of Immediate Jeopardy beginning when staff failed to implement increased monitoring after discovering the bruise while the resident was on medications that increased bleeding risk. The facility census included multiple residents on blood-thinning medications, and staff interviews showed inconsistent understanding of monitoring requirements for warfarin compared to newer anticoagulants, as well as reliance on the resident’s wife and the anticoagulation clinic for INR management without an internal tracking or standardized monitoring process.